Epistaxis: Outpatient Management

240 American Family Physician www.aafp.org/afp Volume 98, Number 4

◆

August 15, 2018

Epistaxis is one of the most common otolaryn-

gologic emergencies, occurring in up to 60% of the

general population, with one in 10 of those aected

seeking medical attention. It accounts for one in

200 emergency department visits.

1,2

Epistaxis has

a bimodal age distribution, peaking in children

younger than 10 years and in adults between 70

and 79 years of age.

1,3

Males are slightly more likely

to experience epistaxis than females.

Anatomy

Approximately 90% of epistaxis cases arise from

the anterior part of the nasal septum; this is

known as anterior epistaxis.

5-7

Anterior bleeding

most commonly occurs from the rich vascular

supply at the Kiesselbach plexus (Figure 1).

is

plexus is formed by terminal branches of the

internal carotid artery (anterior and posterior

ethmoidal arteries) and external carotid artery

(sphenopalatine, superior labial, and greater pal-

atine arteries).

3,6,9

Posterior epistaxis typically occurs along the

nasal septum or lateral nasal wall, and originates

from branches of the internal maxillary, spheno-

palatine, and descending palatine arteries.

3,10

e

posterior ethmoid artery provides a small contri-

bution.

Because hemostasis is more dicult to

achieve with posterior bleeding, the distinction

between anterior and posterior epistaxis guides

management.

Etiology

A focused history and physical examination

identify most causes of epistaxis (Table 1).

3,6

the initial presentation of bleeding, the physi-

cian should determine the side of the bleeding as

well as inquire about previous bleeding episodes

and treatment, comorbid conditions, and med-

ication use.

e dierential diagnosis should

include local and systemic etiologies. In children,

Epistaxis: Outpatient Management

Jason P. Womack, MD; Jill Kropa, MD; and Marissa Jimenez Stabile, DO

Rutgers University Robert Wood Johnson Medical School, New Brunswick, New Jersey

CME

This clinical content conforms to AAFP

criteria for continuing medical education (CME).

See CME Quiz on page 203.

Author disclosure: No relevant ﬁnancial

aliations.

Patient information: A handout on this

topic is available at https:// www.aafp.org/

afp/2005/0115/p312.html.

Epistaxis is a common emergency encountered by primary care physicians. Up to 60% of the general

population experience epistaxis, and 6% seek medical attention for it. More than 90% of cases arise

from the anterior nasal circulation, and most treatments can be easily performed in the outpatient

setting. Evaluation of a patient presenting with epistaxis should begin with assessment of vital signs,

mental status, and airway patency. When examining the nose, a nasal speculum and a good light

source, such as a headlamp, can be useful. Compressive therapy is the ﬁrst step to controlling anterior

epistaxis. Oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine

1: 1,000 may be useful adjuncts to compressive therapy. Directive nasal cautery, most commonly using

silver nitrate, can be used to control localized continued bleeding or prominent vessels that are the

suspected bleeding source. Finally, topical therapy and nasal packing can be used if other methods

are unsuccessful. Compared with anterior epistaxis, posterior epistaxis is more likely to require hos-

pitalization and twice as likely to need nasal packing. Posterior nasal packing is often associated with

pain and a risk of aspiration if it is dislodged. After stabilization, patients with posterior packing often

require referral to otolaryngology or the emergency department for deﬁnitive treatments. (Am Fam

mercial use of one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.

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Volume 98, Number 4 www.aafp.org/afp American Family Physician 241

EPISTAXIS

repeated digital trauma (e.g., nose picking) is the

most common cause. ere are no known specic

conditions or risk factors associated with poste-

rior epistaxis.

3,6

It is unclear whether seasonal

changes or hypertension has a direct role.

4,6,11

Physical Examination

e physical examination should begin with

assessment of vital signs, mental status, and air-

way patency. When examining the nose, a nasal

speculum and good light source, such as a head-

lamp, are useful. e Kiesselbach plexus should

be examined rst for bleeding, followed by the

vestibule, septum, and turbinates. If a bleeding

source cannot be identied in these areas, there

is concern for posterior bleeding. If bleeding per-

sists aer attempts to control anterior bleeding

with compression and packing, management of a

possible posterior source should be initiated.

Management

ANTERIOR EPISTAXIS

Outpatient management of anterior epistaxis is

a stepwise process beginning with conservative

measures to control bleeding and moving toward

more invasive means to achieve hemostasis. An

initial assessment of airway patency is necessary.

A brisk bleed can lead to a large amount of blood

entering the posterior pharynx, potentially caus-

ing airway obstruction. Any concern for airway

obstruction should be immediately referred for

emergency evaluation.

Once airway patency has been determined,

compressive therapy should be applied to stop

bleeding in the anterior nasal plexus. Firm pres-

sure is placed on the bilateral nostrils, below the

nasal bones, for 10 to 15 minutes without interrup-

tion. Simple manual pinching may be used, or a

nasal clip can be fashioned using tongue depres-

sors taped together (Figure 2). To aid compressive

therapy, direct spray of oxymetazoline (Afrin) or

TABLE 1

Causes of Epistaxis

Local

Inﬂammatory

Chronic sinusitis

Environmental irritants

Granulomatous disease

Pyogenic granuloma

Viral illness

Structural

Septal deviation or perforation

Traumatic

Cocaine use

Foreign body

Nasal fracture

Nasal intubation

Nasal oxygen

Nose picking

Surgical procedure

Topical medications (e.g., intranasal steroids)

Tumors and vascular malformations

Systemic

Anticoagulants

Coagulopathy

Hemophilia

Leukemia

Liver disease

Thrombocytopenia

Vitamin deﬁciencies (A, C, D, E, K)

Information from references 3 and 6.

Anterior ethmoid artery

Posterior ethmoid artery

Sphenopalatine artery

Superior

labial artery

Kiesselbach

plexus

Greater palatine artery

FIGURE 1

Vascular anatomy of the nasal cavity.

Illustration by Christy Krames

Reprinted with permission from Kucik CJ, Clenney T. Management

of epistaxis. Am Fam Physician. 2005; 71(2): 305.

mercial use of one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.

242 American Family Physician www.aafp.org/afp Volume 98, Number 4

◆

August 15, 2018

EPISTAXIS

application of cotton soaked in oxymetazoline or

epinephrine 1: 1,000 may be useful to abate or slow

the bleeding.

12,13

Clinicians should be aware of the

adverse eects of systemic epinephrine absorption,

such as elevated blood pressure and tachycardia.

Aer compressive therapy, the nares should

be inspected for any sign of continued bleeding.

Any hematoma must be evacuated for proper

inspection. is can be accomplished through

the patient blowing the nose, suction, irrigation,

or direct forceps evacuation. Proper lighting is

crucial; a headlamp provides adequate lighting

and leaves the hands free to maneuver. A nasal

speculum is useful to increase the eld of vision

during inspection.

e next step is directive therapy. If there con-

tinues to be bleeding or a prominent vessel that is

suspected to be the source of the bleeding, direct

vasoocclusive therapy to the area is warranted.

In the outpatient setting, the use of silver nitrate

sticks is convenient and eective. Silver nitrate

creates a chemical cautery when it comes in con-

tact with a moist mucous membrane. e silver

nitrate should be applied in a circumferential pat-

tern around the site of bleeding before it is applied

to the bleeding site itself. Brisk bleeding will wash

silver nitrate away before cauterization, so relative

hemostasis is needed for this approach to be suc-

cessful.

Electrical desiccation in the same pattern

is also an eective way to control bleeding in the

nares.

Blind cauterization is not recommended,

because excessive destruction of the nasal mucosa

with silver nitrate or electrical desiccation can

lead to ulceration and septal perforation.

If compressive therapy is inadequate and direc-

tive therapy is ineective or impossible because

of continued brisk bleeding, topical therapy and

nasal packing are the next options. Traditional

nasal packing involves placing cotton stripping

impregnated with petroleum jelly into the base

of the nasal cavity, and layering until the nares

are completely compressed (Figure 3).

is is

an eective measure for controlling nasal bleed-

ing, although rebleeding occurs in about 15%

of patients.

Nasal tampons and nasal balloon

packing may be easier to use

; however, unless

the practice treats a large number of patients with

epistaxis, it may not be feasible if these materials

are not readily available.

Nasal packing should be le in place for 48

hours. e use of oral and topical antibiotics in

patients with nasal packing is common to prevent

infectious complications such as staphylococcus-

induced toxic shock syndrome and sinusitis, but

there is little evidence to support antibiotic use.

Topical hemostatic agents such as Floseal and

Surgicel may be eective for managing epistaxis,

but are oen unavailable in the outpatient setting.

POSTERIOR EPISTAXIS

Posterior epistaxis is oen brisk, and given the

location of these vessels, it is usually dicult to

visualize the site of bleeding. Compared with

anterior epistaxis, patients with posterior epi-

staxis are more likely to require hospitalization

and are twice as likely to require nasal packing.

FIGURE 2

Nasal compressive device using tongue

depressors.

August 15, 2018

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EPISTAXIS

As with anterior epistaxis, the physician should

evaluate and clear the airway, and provide intra-

venous access and uid resuscitation, if needed.

Patients with posterior epistaxis generally require

referral to an otolaryngologist aer stabilization.

Chemical cautery is usually not possible for

posterior epistaxis because the source of bleed-

ing is rarely identied.

18,19

Newer products that

can adhere to an irregular moist surface, such as

gelatin-thrombin matrix,

are still being tested,

and there is no evidence to support their blind

application.

Posterior nasal packing may be attempted by

a physician trained in this procedure. It is up to

70% eective at treating posterior epistaxis when

performed by trained physicians

; however, it is

not as successful as endoscopic or surgical man-

agement, and may be less cost-eective as an ini-

tial management technique.

20,22,23

Nonetheless, it

is a common procedure that may be attempted

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation

Evidence

rating References

Compressive therapy should be the ﬁrst intervention to stop anterior epistaxis. C 12, 13

Silver nitrate and electrical desiccation are eective at stopping anterior epi-

staxis in patients when compressive therapy is unsuccessful.

C 10, 14

When available, endoscopic artery ligation may be the best initial treatment

for posterior epistaxis because it is more eective than packing and less costly

than endovascular embolization.

B 20, 22, 23

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence;

C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the

SORT evidence rating system, go to https:// www.aafp.org/afpsort.

FIGURE 3

Packing of the anterior nasal cavity using gauze strip impregnated with petroleum jelly. (A) Gauze is gripped with

bayonet forceps and inserted into the anterior nasal cavity. (B) With a nasal speculum (not shown) used for exposure,

the ﬁrst packing layer is inserted along the ﬂoor of the anterior nasal cavity. Forceps and speculum then are with-

drawn. (C) Additional layers of packing are added in an accordion-fold fashion, with the nasal speculum used to hold

the positioned layers down while a new layer is inserted. Packing is continued until the anterior nasal cavity is ﬁlled.

Illustration by Christy Krames

Reprinted with permission from Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005; 71(2): 309.

Bayonet

forceps

A CB

244 American Family Physician www.aafp.org/afp Volume 98, Number 4

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August 15, 2018

EPISTAXIS

in the outpatient setting or en route to an emer-

gency department.

Posterior packing is performed using a bal-

loon catheter, Foley catheter, or red rubber cath-

eter with cotton packing. e catheter is passed

through the nostril, down the nasopharynx, and

into the oropharynx (Figure 4).

e balloon

is inated with 8 to 10 mL of water and gently

retracted until it sits in the posterior choana. If

cotton packing is used, the rubber catheter is

drawn out of the mouth aer it is visualized in

the oropharynx. e packing is secured to the

end of the catheter and then pulled back through

the mouth to sit in the choana. In each case, trac-

tion is maintained by clamping the area outside

of the nostril, making sure to provide padding

between the clamp and the nasal ala to minimize

the risk of alar necrosis.

Posterior packing is oen associated with pain,

and there is a risk of aspiration if it is dislodged.

Patients are commonly monitored in the hos-

pital while packing is in place. ere is up to a

FIGURE 4

Posterior nasal packing. (A) After adequate anesthesia has been administered, a catheter is

passed through the aected nostril and through the nasopharynx, and drawn out the mouth

with the aid of ring forceps. (B) A gauze pack is secured to the end of the catheter using umbil-

ical tape or suture material, with long tails left to protrude from the mouth. (C) The gauze pack

is guided through the mouth and around the soft palate using a combination of careful traction

on the catheter and pushing with a gloved ﬁnger. This is the most uncomfortable (and most

dangerous) part of the procedure; it should be completed smoothly and with the aid of a bite

block (not shown) to protect the physician’s ﬁnger. (D) The gauze pack should come to rest in

the posterior nasal cavity. It is secured in position by maintaining tension on the catheter with

a padded clamp or ﬁrm gauze roll placed anterior to the nostril. The ties protruding from the

mouth, which will be used to remove the pack, are taped to the patient’s cheek.

Illustration by Christy Krames

Reprinted with permission from Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005; 71(2): 310.

Gauze roll

Catheter

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EPISTAXIS

50% chance of rebleed with posterior epistaxis.

Telemetry may be considered given the possibil-

ity of a vasovagal reex, which can cause cardiac

abnormalities and respiratory arrest.

If clinicians with appropriate expertise are

available, endoscopic artery ligation and endo-

vascular embolization are more eective than

packing.

20,22,23

Endoscopic treatment may be the

best initial treatment, because it is less costly than

embolization and more eective than packing.

This article updates a previous article on this topic by

Kucik and Clenney.

Data Sources: Literature search included the use

of medical databases PubMed, Ovid, and Essential

Evidence Plus. Keywords used included epistaxis,

anterior epistaxis, posterior epistaxis, epistaxis man-

agement. Search dates: February 1 to May 15, 2017.

The Authors

JASON P. WOMACK, MD, is an assistant professor

in the Department of Family Medicine and Com-

munity Health at Rutgers University Robert Wood

Johnson Medical School, New Brunswick, N.J. Dr.

Womack is also the director of the sports medi-

cine fellowship.

JILL KROPA, MD, is an assistant professor in the

Department of Family Medicine and Community

Health at Rutgers University Robert Wood John-

son Medical School.

MARISSA JIMENEZ STABILE, DO, is an assistant

professor in the Department of Family Medicine

and Community Health at Rutgers University Rob-

ert Wood Johnson Medical School.

Address correspondence to Jason P. Womack,

MD, Rutgers University Robert Wood Johnson

Medical School, 1 Robert Wood Johnson Pl., MEB

2nd Fl., New Brunswick, NJ 08903 (e-mail:

womackja@rwjms.rutgers.edu). Reprints are not

available from the authors.

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